How a dramatic decline in hepatitis C infections in England brings us close to elimination

Our latest data reveals a 56.7% decline in chronic hepatitis C virus (HCV) infections across England. With cases dropping from an estimated 129,400 in 2015 to 55,900 in 2023, significant strides have been made towards eliminating HCV in England.

The barriers to elimination

This bloodborne virus can lead to life-threatening liver disease and cancer if diagnosed late or untreated. The decline in people living with the virus is largely due to increased testing and improved access to Direct Acting Antivirals (DAAs) since 2015. DAAs cure most people of hepatitis C. Early detection and treatment can also reduce the risk of passing the virus onto others.

The virus spreads through blood-to-blood contact, most commonly in the UK through sharing needles, syringes or other non-sterile injecting equipment. Other people at risk of acquiring the infection are those who:

• have spent time in prison
• have experienced homelessness
• have received medical procedures or tattoos abroad
• come from countries with higher HCV prevalence
• received blood transfusions or a blood product before widespread screening was introduced in the UK

Combating resistance with genomic surveillance

To maintain momentum, we have launched a groundbreaking genomic surveillance programme for HCV. This technology will monitor for genetic markers of drug resistance, which is emerging as a concern in the fight against hepatitis C.

Data from 2023 showed that 5% of samples containing one of the most common classifications of hepatitis C (genotype 1, subtype 1a), from patients who were new to treatment, were resistant to one class of HCV antiviral drugs. Additionally, some HCV subtypes prevalent in Asia and sub-Saharan Africa - but also found in the UK - show inherent resistance to certain DAAs.

Dr Monica Desai , hepatitis C lead at UKHSA, explains, ‘Effective anti-viral drugs have played a huge part in driving down hepatitis C in this country, but we must always be alert to the emergence of resistance, potentially jeopardising progress. Through our genomic surveillance programme we can monitor changes in how the virus is responding to treatment and more quickly respond if resistance increases.’

This surveillance can also help detect outbreaks sooner and provide insights into transmission patterns, which will be important for preventing ongoing transmission among at-risk populations.

The NHS elimination programme: a transformative approach

The dramatic decline in HCV infections can be largely attributed to NHS England's HCV Elimination Programme, which has taken a multi-faceted approach including:

• increased testing across various settings
• improved access to highly effective Direct Acting Antiviral (DAA) treatments
• test-and-treat initiatives in prisons and probation services
• emergency department and pharmacy testing programmes
• a national home testing service launched in May 2023

These efforts have yielded impressive results. Around 78.3% of those diagnosed with HCV in England between 2015 and 2023 have initiated treatment, bringing us close to the World Health Organization's (WHO) target of 80%. Hepatitis C-related mortality has fallen to its lowest level in nearly a decade, from 0.69 per 100,000 people in 2015 to 0.41 per 100,000 in 2023 - well below the WHO target of 2 per 100,000.

Challenges on the path to elimination

Despite significant progress, substantial challenges remain.

While chronic HCV prevalence among people who inject drugs fell to 7.2% in 2023, over one third were potentially unaware of their status. Although 58.1% of people in England who inject drugs and are dependent on opioids receive opioid agonist therapy like methadone (exceeding WHO goals), a third of people who injected drugs in the past year report inadequate access to needle and syringe programmes. The UK Government’s 10-year Drug Strategy released in April 2022, outlined significant investment for harm reduction to be used by local authorities with an aim to maintain and improve access to harm reduction services to prevent infection and reinfection.

The final phase of elimination and sustained maintenance will require person-centred and holistic interventions for populations poorly reached by existing services and further investment in harm-reduction services.

Looking ahead

The clear progress made to date demonstrates that HCV elimination is achievable with sustained commitment. The coming years will require continued vigilance, innovation, and resource allocation to reach those who remain undiagnosed and to prevent new infections.

As we approach possible elimination of hepatitis C in England, this public health success story offers hope and lessons for tackling other persistent health challenges in our society.